Exposure to the dust and fumes of the World Trade Center (WTC) disaster resulted in adverse health effects with upper and lower respiratory symptoms (LRS) in populations of responders and community members. The Bellevue Hospital WTC Environmental Health Center (WTC EHC) is a treatment program started in 2005 to target community members, now called Survivors, including local residents, local workers and clean-up workers with WTC dust and fume exposures. Lower respiratory symptoms (cough, wheeze, dyspnea, chest tightness) are prevalent in patients in this program. Despite treatment, eleven years after the destruction of the WTC towers, many patients in the WTC EHC report incomplete clinical response with continued lower respiratory symptoms. Patients with continued uncontrolled lower respiratory symptoms (LRS) remain on treatment with long-term high dose ICS often with additional LABA use, rendering them at risk for adverse health effects of long term ICS treatment. The persistence of symptoms, despite therapeutic interventions, necessitates a reevaluation and a search for causes of persistent symptoms. Our overall hypothesis is that WTC EHC patients with uncontrolled LRS despite aggressive medical therapy have increased rates of abnormal airway physiology, airway inflammation and co-morbid conditions when compared to those with controlled symptoms. Identifying these mechanisms for uncontrolled LRS is imperative to guide therapy with the important potential to reduce secondary adverse health outcomes. We will test this hypothesis using a prospective study with the following aims: Specific Aim 1: To test the hypothesis that despite aggressive treatment for lower respiratory tract symptoms there is a continued group of patients with uncontrolled lower respiratory symptoms (ULRS) that differ from those with controlled lower respiratory symptoms (CLRS). Specific Aim 2: To test the hypothesis that discrete measures of lung physiology are associated with patients in the WTC EHC with URLS compared to CLRS Specific Aim 3: To test the hypothesis that higher levels of inflammatory markers (FeNO, peripheral eosinophils, C-reactive protein, serum periostin) are associated with WTC EHC patients with ULRS compared to CLRS. Specific Aim 4: To test the hypothesis that increased rates of comorbid conditions are associated with WTC EHC patients with ULRS compared to those with CLRS. Characterization of the physiologic findings, inflammatory response and co-morbid conditions in these patients has the potential to guide treatment with reduced medication risk for this population and will provide clues for future investigations in other populations with environmental induced lower respiratory disease or asthma.